Arch. Biol. Sci., Belgrade, 65 (3), 1181-1187, 2013
DOI:10.2298/ABS1303181P
POPULATION-BASED CASE-CONTROL STUDY OF BREAST CANCER IN ALBANIA
E. PAJENGA1, T. REXHA2, S. ÇELIKU3 and E. MARIANI4.
1
Department of Biology and Chemistry, Faculty of Natural Science, University of Elbasan, Elbasan, Albania
2
Department of Biology, Faculty of Natural Science, University of Tirana, Tirana, Albania
3
Division of Gynecology, Oncology Hospital “Mother Tereza”, Tirana, Albania
4
Division of Public Health, Ministry of Health, Tirana, Albania
Abstract - In Albania, breast cancer is an important cause of death among women, with increasing incidence from 65 cases
in 1970, to 400 cases in 2007. This is the first study concerning breast cancer risk factors in Albania. We used a populationbased case-control study of 948 women with breast cancer compared with 1019 controls recruited from other hospitals
through random selection. Early age at menarche was found to be a significantly strong risk factor during the pre- and
postmenopausal groups with OR 10.04 and 12.1, respectively. In addition, nulliparity is associated with higher risk while
abortion did not indicate any influence in the multivariate model. The findings from this study have shown that reproductive and menstrual variables are significant predictors of breast cancer risk in Albanian women, as seen in studies of other
western countries.
Key-words: Breast cancer, reproductive factors, menstrual factors, multivariate analysis.
INTRODUCTION
pared with those of other populations. The fertility
rate in 1960 of more than 5 children per woman of
childbearing age has changed to 1.4 children in 2010,
while the number of abortions has doubled during
2010 compared to 1993 (Bregu et al., 2010). The nutrition situation is optimal, mainly in urban areas,
which affects major sections of the resident population.
Risk factors for breast cancer (BC) are widely analyzed in countries with high incidence rates, while
the epidemiology of breast cancer in Albania, a
country characterized by low incidence, remains unclear. Thus, in Albania, the incidence of breast cancer is much lower than in other European countries,
with the incidence rate per 100,000 women being
48.2 compared to 89.7 in Western Europe (Ferlay et
al., 2010).
Epidemiological risk factors for BC include
hormonal factors (Timothy et al., 1999) such as
early menstruation (Claver-Chapelon et al., 2002;
Gao et al., 2000) and late menopause (Hsieh et al.,
1990; Fioretti et al., 1999), nulliparity (Miller 1993;
Layde et al., 1993) and pregnancy at an advanced age
(Bruzzi et al., 1988; Kvale et al., 1987), all of which
indicate prolonged estrogenic exposure (Kesley and
Nevertheless, breast cancer rates have been rising
in Albania, accounting for 22.9% of all cancer cases,
and it is the most common malignancy in women
and fourth leading cause of mortality (Ferlay et al.,
2010). Albanian women have a number of different
reproductive experiences and lifestyle habits com1181
1182
E. PAJENGA ET AL.
Hilderth, 1983; Key, 1995; Timothy et al., 1999; Gao
et al., 2000).
The age at which a woman gives birth to her first
live child is predictive of breast cancer risk and the
risk increases with age at first birth. The importance
of age at first birth as a risk factor was first established by MacMahon et al. in 1970, from a large
international case-control study. Since then, many
epidemiologic studies have revealed that, on average,
the younger a women is when she has her first-full
term pregnancy, the lower is her risk of breast cancer
(Lubin et al., 1982; Hinkula et al., 2001; Palmer et
al., 2003). Parity has influence in levels of circulating
hormones such as estradiol, PRL and GH and in the
differentiation of epithelial cells that are less susceptible to transformation. In postmenopausal women,
obesity, which is positively correlated with plasma
estrogen and estradiol levels, is associated with an
increased risk of breast cancer.
To analyze the reason for the increased breast
cancer rate in Albania and to determine if factors in
this low-incidence country differ from those identified in other countries, we conducted a populationbased case-control study of 948 breast cancer patients, during the period 1998 to 2006.
MATERIALS AND METHODS
Data collection
A case-control design of 948 women with breast cancer and their 1019 female controls was carried out
from 1998 till 2006. All women between 20 and 74
years of age who were diagnosed with a primary, invasive breast cancer between September 1, 1998, and
December 31, 2006, were eligible as cases and were
identified using the Albanian Central Cancer Registry. This center compiles information from reports of
all malignant tumors and is a part of the Oncology
Hospital, which is the only institution offering these
services within the health sector in Albania.
After exclusion of nine women who had incomplete information on many risk factors of interest,
information from 948 cases was available for analysis. Of the 1204 eligible women, 185 (15%) declined
to participate. Thus, information from 1019 controls
was available for analysis, for an overall cooperation
rate of 85%. Diagnoses were confirmed histologically, through a biopsy.
In the present study, cases were defined as women that were interviewed at the oncology services of
the hospital, who presented clinical and cytological reasons to suspect the presence of breast cancer.
Women in the same range and residential area but
without a history of breast cancer were eligible as
controls. Controls were obtained from other hospitals through random selection for a variety of acute
conditions unrelated to the hypotheses in the study.
These women were outpatients receiving primary
care in the same source area as the cases. The main
reasons for the selected controls visiting the outpatient clinic were gastrointestinal upsets (31%), respiratory infections (23%), and skin diseases (17%),
among others. The team of interviewers was previously trained in the logistic aspects of this study. Interviewers administered a structured questionnaire
in which they were asked tp answer questions related to their (a) age, marital status, age at menarche,
number of abortions, age at first delivery, number
of children, age at menopause and family history of
breast cancer; (b) diagnosis year, per year (1998 referent); (c) tumor stage (stage 1 referent); (d) tumor
size (0 to <1 cm [referent], 1 to <2, 3 to <4, 4 to <5,
5 to <10, ≥10); (e) axillary nodal positivity (0 [referent], 1 to 3, 4 to 10, ≥11; for all cases, consent for
access to medical documentation was obtained. A
pregnancy was classified as full-term if it resulted in
a live birth or lasted 7 or more months; otherwise, it
was considered an abortion.
Women were classified as postmenopausal if
their cycles ended naturally or from radiation therapy
(prior to diagnosis for cases), from surgery in which
both the uterus and ovaries were removed, or from
surgery in which at least one ovary remained intact
but age at diagnosis or selection was more than 55
years. Also considered postmenopausal were women
who mentioned experiencing menopausal symptoms
POPULATION-BASED CASE-CONTROL STUDY OF BREAST CANCER IN ALBANIA
after surgery or receiving hormone replacement therapy, although they had never stopped menstruating
and were older than 55 years of age. The remaining
women who reported not having menstrual cycles
were considered perimenopausal and were grouped
with premenopausal women for analysis.
We started obtaining information on tumor
histology from the pathology report in the medical record since 2002. Four hundred and sixty three
cases were classified according to the invasive component, as being ductal (n = 287), lobular (n = 176)
or of other types (82). We analyzed only ductal and
lobular cases and all other cases were excluded from
the analyses. The study protocol was approved by the
Institutional Review Board of Tirana University in
February 2007.
Data analysis
Odds ratios and 95% confidence intervals comparing
each case subgroup with controls were calculated for
risk factors to estimate relative risks. All primary exposure variables, as well as age, were included in the
models to account for potential confounding effects.
The collected data were initially cleaned through an
analysis of the range and distribution of study variables and their mutual consistency. Distribution of
study factors was then calculated for cases and controls, as well as the respective odds ratios, 95% confidence intervals, and significance tests. Binary logistic regression models were run by using Statistical
software SPSS Incorporation 15 for Windows. All
statistical tests were two-sided, and p values of 0.05
or less were considered significant. Data were then
submitted to multivariate analyses, employing logistic regression (Breslow and Day, 1980).
RESULTS
Of the 981 case subjects diagnosed with breast cancer during the 9 years of follow-up, 503 were premenopausal and 478 were postmenopausal women.
The mean age of cases was 49.5 years and 50.2 years
among controls. The baseline distribution of parity,
age at first birth, number of children born, age at
1183
menarche and menopause for the 981 breast cancer
cases and 1019 controls are given in Table 1. The age
distribution of cases was as follows: 7.2% < 35 years,
30.8% from 36 to 45 years, and 59.9% 45 to 60 years.
The age distribution of controls was 10.5% < 35 years,
20.7% from 36 to 44 years, and 72.1% from 45 to 60
years. The proportion of these types increased with
age to a maximum at 44-54 years and decreased in
the following decade.
Among premenopausal women, 19.3 % were
nulliparous and 49.8% had had one to two births.
Among postmenopausal, 14.6% were nulliparous
and 32.3% had had one to two births.
Multivariate analysis was performed separately
for premenopausal and postmenopausal women.
Compared to premenopausal women whose age
at first childbirth was below 20 years, women at 30
years or more (Table 2) had a risk OR=15.7 (95%
CI=4.8-50.7). This variable remained insignificant
for postmenopausal women.
Most of the parous women had had their first full
term pregnancy at an early age: 60% of premenopausal and 72% of postmenopausal women had had their
first full term pregnancy before age 25. Compared
to women with a parity of five children and more,
women with no children were at a 20% insignificant
risk; this was the same risk only in the postmenopausal group. Parity and abortion did not indicate
any protection in the multivariate model even in the
menopausal groups (Table 2).
An early age at menarche was found to be a
strong risk factor. Age 12 years or younger increased
the risk 10.04-fold in premenopausal and 12-fold in
postmenopausal women (Table 2) and an older age
at menarche was associated with a significant reduction in the risk of breast cancer in the two groups
accordingly. Compared to postmenopausal women,
premenopausal women had a 68% increased risk for
breast cancer. Age at menopause was found to have
a 2.3-fold higher risk for women aged 50 and more
compared with those under 50 years (95% CI = 1.13.2).
1184
E. PAJENGA ET AL.
Table 1. Comparison of reproductive variables in breast cancer in Albanian women.
Variables
Mean (cases)
SD
Age
47.05
9.019
Age at first birth
23.51
3.721
Number of children
2.48
1.926
Age at menopause
50.41
5.403
Age at menarche
13.38
1.691
Mean (controls)
SD
p-value
52.4
52.4
<0.01
22.46
3.052
0.000
3.17
1.427
0.000
42.2
15.481
0.000
14.65
1.534
0.000
*student t-test
Table 2. Odds ratios in multivariate analysis for breast cancer according to selected risk factors in Albanian women, 1998-2006.
All women
Cases/Controls
Premenopausal
Postmenopausal
OR
95%CI
OR
95%CI
OR
95%CI
Age at menarche*
<=12
320/52
8.30
4.6-15.4
10.0
5.6-17.9
12.0
6.5-22.1
13
206/160
1.79
1.0-3.1
2.9
1.7-4.8
2.3
1.3-3.8
14
212/325
1.07
0.6-1.8
1.4
0.9-2.2
2.0
1.2-3.2
15
98/222
0.66
0.3-1.1
1.1
0.6-1.8
0.8
0.4-1.5
>=16
112/260
1.0
1.0
1.0
<20
104/142
1.0
1.0
1.0
20-24
429/652
1.28
0.5-2.9
1.3
0.7-2.5
0.7
0.4-1.1
25-29
234/208
1.69
0.6-4.2
2.0
1.0-3.9
1.0
0.5-1.7
>=30
46/17
2.06
0.6-6.7
15.7
4.8-50.7
0.3
0.1-1.0
Age at first full-term pregnancy (years)*
Parity*
0
156/9
1.48
0.4-4.5
0.5
0.1-2.4
1.19
0.5-2.3
1-2
390/357
0.61
0.2-1.8
0.3
0.1-1.4
0.5
0.2-1.0
3- 4
285/503
0.76
0.2-2.4
0.4
0.1-2.1
0.7
0.3-1.3
>=5
117/150
1.0
1.0
1.0
1.0
1.0
Menopausal status**
Premenopausal women
503/551
1.68
Postmenopausal women
478/468
1.00
1.0-2.6
Postmenopausal women >50 year
144/313
1.0
Postmenopausal women ≥50 year
334/155
2.3
Yes
212/294
1.0
No
736/725
1.6
1.1-2.4
Yes
96/68
1.4
0.8-2.6
No
852/951
1.1-3.2
Aborts*
1.2
0.8-1.7
1.7
1.1-2.5
Family history*
*Adjusted for age, age at first birth, age at menarche, age at marriage, interval between menarche and age at first birth, number of births,
family history, abortions, menopause status. **Adjusted for age at first birth, age at menarche, age at marriage, interval between menarche and age at first birth, number of births, family history, abortions.
POPULATION-BASED CASE-CONTROL STUDY OF BREAST CANCER IN ALBANIA
In our study, there was differential protection
against subtypes of breast cancer. Increased age at
menarche reduced risk in lobular cancer but increased risk in ductal. Early menopause was a protective factor only for ductal cancer and had an opposite
effect on the lobular type. A positive family history of
breast cancer is associated positively with ductal but
not with lobular cancer.
Multiparity, early age at first delivery, and late
age at menarche significantly reduced the frequency
of ER+, PR+ cancers and did not influence ER-, PRcancers.
DISCUSSION
For the past one and a half decades, Albania’s society
has witnessed rapid economic growth and major demographic change along with a sizable rural-urban
population migration that are associated with significant reproductive and lifestyle changes. Therefore,
in this study we intended to clarify the role of breast
cancer risk factors in the Albanian population, and
since there is a shortage of data on breast cancer risk
factors among women in low-risk countries, the results are of interest, particularly when compared with
studies in other areas of the world.
The age at menarche indicated a positive association with breast cancer risk. Late age at menarche offered strong protection in premenopausal and postmenopausal years. A significant reduction in the risk
of breast cancer was found in some studies (Nagata
et al., 1995; Gao et al., 2000; Claver-Chapelon and
E3N-Epic Group, 2002). Several studies carried out
in a high-risk population found no association between age at menarche and the risk of breast cancer
(Adami et al., 1978; Talamini et al., 1996). Negative
association was found between increasing age at menarche and breast cancer risk in women born before
1925, but not after (Magnusson et al., 1999).
In multivariate analysis, a young age at first birth
was protective against breast cancer only in premenopausal women. A 15-fold elevated risk of breast
cancer was observed when the age at first childbirth
1185
was after 29 years. A consistent finding reported in
many epidemiologic studies was that the younger
a woman is when she has her first childbirth; the
lower is her risk of breast cancer (Leon et al., 1989;
Paffenbarger et al., 1980; Negri et al., 1988; Okobia
et al., 2006). An excess risk ranged from 2-5-fold
or increase in risk by 3-5% per year of delay in age
at first birth for women with a birth after 30 years
compared to those with a birth prior to 18 years,
has been reported by several studies (Nagata et al.,
1995; Hinkula et al., 2001). Some studies found no
positive association between age at first birth and
the risk of breast cancer (Ewertz et al., 1988; Huo
et al., 2008). The influence of age at first birth and
age at menarche may indicate that events early in
life matter most in determining breast cancer risk.
Recall bias was not considered to be a major source
of error because it was unlikely that healthy women
or women with breast cancer would misreport the
years of birth of their children.
Low parity was found to be significantly associated with an increased risk of breast cancer (Gomes
et al., 1995; Romieu et al., 1996; Magnusson et al.,
1999). Nulliparity was associated with an increased
risk of 27-30% compared with parous women (Ewertz et al., 1990; McCredie et al., 1998). A protective
effect of high parity was found only for postmenopausal women (Claver-Chapelon F and E3N-Epic
Group, 2002). In our study, parity did not emerge
as a risk factor for breast cancer. The significant risk
found in premenopausal and postmenopausal nulliparous women observed in univariate analysis disappeared in the multivariate model.
Premenopausal women have an increased risk
compared to postmenopausal women. This elevation in risk indicates that existing tumors may have
an increased growth rate at the time of menopause.
Among postmenopausal women, late age at menopause was found to be associated significantly with
the risk of breast cancer, suggesting that late menopause has higher risk of breast cancer.
A large number of epidemiological studies have
suggested that age at menopause is an important de-
1186
E. PAJENGA ET AL.
terminant in breast cancer. Late age at menopause
was found to be associated with an increased risk
of breast cancer (Schatzkin et al., 1987; Bruzzi et al.,
1988; Talamini et al., 1996; Fioretti et al., 1999) which
points out the quality of our study. It is possible that
the two factors, early age at menarche and late age at
menopause, indicate an influence of the total numbers of years of menstrual activity (Henderson et al.,
1988). In our study, cases more commonly reported
a familial cancer history, although reproductive cancers did not predominate. Familial cancer history
was positively related to BC risk and thus it would
appear that heredity is a contributing factor to the
etiology of breast cancer in Albania.
Young age at first birth and late age at menarche
may affect the hormonal characteristics of breast
cancer, as each of them was associated with a reduced frequency of ER+PR+ breast cancer (Ursin et
al., 2005; Britt et al., 2007).
In conclusion, we established protection from
breast cancer as early age at first birth among premenopausal women, late age at menarche in both
groups, and early age at menopause. The risk of breast
cancer was not associated with parity. In general, the
results show that risk factors for Albanian women
are similar with those found in western countries, although there are also considerable differences in the
incidence rates.
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